NHS Never Events

This consulation is now closed. Thank you to everyone who contributed. Comments submitted during the consultation can still be viewed on this site.

“Never events” are defined as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers.

High Quality Care For All published in June 2008 proposed that a “never events” policy be introduced for the NHS in England from April 2009. The National Patient Safety Agency (NPSA) subsequently co-produced a set of criteria for defining “never events” and agreed a core list of eight events, alongside a policy framework, to assist commissioners in implementing the “never event” proposals.

From April 2009 to March 2010, the framework provided a lever for increasing the transparency of organisations and the levels of reporting and learning around these very serious safety incidents. This provided an increased impetus for reducing and preventing their incidence, and encouraged commissioners to work with their providers to actively improve the safety of the care people receive.

In March 2010, the NPSA published Never Events – Framework: Update for 2010-11. This outlined how existing arrangements for “never events” should continue, taking account of policy developments, but also refined the core list of “never events” and described new arrangements, specified in The operating framework for the NHS in England 2010/11, for how PCTs should seek to recover the costs of any procedure/treatment where a “never event” occurs. The NPSA have also now produced an annual report providing a summary of the first 12 months of the “never event” framework.

In the NHS White Paper published in July 2010, the Government committed to build on these changes and to proceed with work to impose contractual penalties for an extended list of “never events”.

Proposals have now been produced by the Department of Health in order to engage the NHS and our external partners in the process for expanding the national list of “never events” and implementing new contractual penalties “never events” occur.

The Government wishes to maintain and increase the focus on safety in the NHS, especially through encouraging the reporting of patient safety incidents and ensuring that lessons are learned and implemented. However, it is also clear that serious failure will not be tolerated, especially where there are clear guidelines and procedures in place to support organisations in preventing serious incidents. Therefore, where serious failings still occur, organisations will be subject to serious sanctions, emphasising a more firm approach to “never events”.

Commissioners and providers are currently free to negotiate their own locally agreed quality requirements in addition to the quality requirements set centrally, which could include local “never events”, along with any appropriate locally agreed contractual arrangements as they see fit. There are examples around the country where local health care communities have embraced this idea. These do not replace the requirement to use the national core “never events”.

This proposition is only concerned with the national core list of “never events” and does not seek to change these local arrangements. However for the purposes of simplicity we propose that locally determined “never events” should not duplicate nationally determined ones and suggest that the national event should take precedence. If you have any comments about this position however, please feed them back via the routes explained below.

Equally, we are not seeking to amend the arrangements set out in the current “never event” Framework for how organisations are expected to work together to report “never events” to each other and to the public in their annual reports and to fully investigate and share learning from events that occur. Organisations should continue to follow the arrangements as set out for all core, national “never events”.

The Department has produced an expanded list of “never events” and is proposing revisions to the NHS standard contracts (acute hospital, mental health and learning disability , community and ambulance services). We are looking for clinicians, managers, commissioners, subject experts and other interested parties to review the list we have produced and make suggestions for amendments in the context of the clear criteria that have been defined.

You can download a copy of the proposal here, or you can read each chapter on screen by clicking through the pages listed in the ‘have your say’ panel on the right hand side.

At the bottom of each page you can write your thoughts about that section of the plan and read comments left by others. All comments will be considered before the final draft is published.

Please keep your comments concise and related to the ideas set out in the plan. Comments are pre-moderated and will not be published immediately. You can read our moderation policy and Information Charter.

The engagement process will run for 6 weeks from 8 October 2010 until 19 November, after which we will refine our proposals according to the comments received and produce a final version of the “never event” list and associated contractual framework. We will look to incorporate the policy arrangements in the 2011/12 NHS Operating Framework and 2011/12 NHS Standard Contracts, subject to Ministerial agreement and the financial context and priorities determined by the forthcoming Spending Review.

The engagement process is open to all, however we are most actively seeking input from clinicians and other professionals due to the technical nature of the NHS contracting system and the requirement for detailed subject knowledge in order to assess the suitability of the suggested “never events” and to propose additions or amendments. Any queries about this process should be addressed to neverevents@dh.gsi.gov.uk.